REFERAT

TESTICULAR TORSION

By:

IRFAN PRATAMA

H1A 0050 25

Supervisor:

dr. Akhada Maulana, Sp.U

BACKGROUND

Testicular torsion is when the spermatic cord to a testicle twists, cutting off the blood

supply. The most common symptom is acute testicular pain and the most common underlying

cause is a congenital malformation known as a "bell-clapper deformity". The diagnosis is often

made clinically but if it is in doubt an ultrasound is helpful in ruling in or out the condition.

Acute scrotal swelling in children indicates torsion of the testis until proven otherwise. In

approximately two thirds of patients, history and physical examination are sufficient to make an

accurate diagnosis. Emergency diagnosis and treatment is required in order to save the viability

of the testicle. Patients often complain of acute-onset scrotal discomfort, which may occur at rest

or may relate to sports or physical activities. They may describe similar previous episodes, which

may suggest intermittent testicular torsion.[1] Patients deny voiding problems or painful urination

but may describe nausea and vomiting.

Testicular torsion refers to twisting of the spermatic cord structures, either in the inguinal

canal or just below the inguinal canal

 Extravaginal torsion: This type manifests in the neonatal period and most commonly

develops prenatally in the spermatic cord, proximal to the attachments of the tunica

vaginalis.

 Intravaginal torsion: This type occurs within the tunica vaginalis, usually in older

children. Intravaginal torsion is related to an anomalous testicular suspension that has

been referred to as the bell-clapper anomaly. In many instances, this anomaly may be

bilateral
  Relevant Anatomy

For normal development and sperm production, the testis must descend from its original

position near the kidney into the scrotum. Researchers propose that various mechanisms,

including gubernacular traction and intra-abdominal pressure, are responsible for testicular

descent; however, endocrine factors of the hypothalamic-pituitary-testicular axis also play a

major role in this process. Between the 12th and 17th week of gestation, the testis undergoes

transabdominal migration to a location near the internal inguinal ring. The testis does not migrate

transinguinally to its final position until the seventh month of gestation.

The testes are paired ovoid structures that are housed in the scrotum and positioned so

that the long axis is vertical. The anterolateral two thirds of the organ is free of any scrotal
attachment. The epididymis, connective tissue, and vasculature cover the posterolateral aspect of

the organ. The capsule of the testis is termed the tunica albuginea.

Risk factors

Congenital

Conditions that allow the testicle to rotate predispose to torsion.[2] A congenital

malformation of the processus vaginalis known as the "bell-clapper deformity" accounts for 90%

of all cases.[3] In this condition, rather than the testes attaching posteriorly to the inner lining of

the scrotum by the mesorchium, the mesorchium terminates early and the testis is free floating in

the tunica vaginalis.

Size

A larger testicle either due to normal variation or a tumor increases the risk of torsion.[2]

Temperature

Torsions are sometimes called "winter syndrome". This is because they often happen in

winter, when it is cold outside. The scrotum of a man who has been lying in a warm bed is

relaxed. When he arises, his scrotum is exposed to the colder room air. If the spermatic cord is

twisted while the scrotum is loose, the sudden contraction that results from the abrupt

temperature change can trap the testicle in that position. The result is a testicular torsion.[4]
Epidemiology

Frequency

 Extravaginal torsion comprises approximately 5% of all torsions. The condition is most

often a prenatal (in utero) event and is associated with high birth weight. Up to 20% of

cases are synchronous, and 3% are asynchronous bilateral.

 Intravaginal torsion comprises approximately 16% of patients with torsion presenting in

emergency departments with acute scrotum. Peak incidence occurs in adolescents aged

13 years, and the left testis is more frequently involved. Bilateral cases account for 2% of

all torsions.

Etiology

 Extravaginal torsion: The testes may freely rotate prior to the development of testicular

fixation via the tunica vaginalis within the scrotum.

 Intravaginal torsion: Normal testicular suspension ensures firm fixation of the

epididymal-testicular complex posteriorly and effectively prevents twisting of the

spermatic cord. In contrast, the bell-clapper deformity allows torsion to occur because of

a lack of fixation, resulting in the testis being freely suspended within the tunica

vaginalis. A large mesentery between the epididymis and the testis can also predispose

itself to torsion, although this is rare. Contraction of the spermatic muscles shortens the

spermatic cord and may initiate testicular torsion.

Pathophysiology

Torsion of the spermatic cord may interrupt blood flow to the testis and epididymis. The

degree of torsion may vary from 180-720°. Increasing testicular and epididymal congestion

promotes progression of torsion.

The extent and duration of torsion prominently influence both the immediate salvage rate

and late testicular atrophy. Testicular salvage most likely occurs if the duration of torsion is less

than 6-8 hours. If 24 hours or more elapse, testicular necrosis develops in most patients.

Clinical symptoms

Prenatal torsion manifests as a firm, hard, scrotal mass, which does not transilluminate in

an otherwise asymptomatic newborn male. The scrotal skin characteristically fixes to the

necrotic gonad.

In older boys, the classic presentation of testicular torsion is the sudden onset of severe

testicular pain followed by inguinal and/or scrotal swelling. Pain may lessen as the necrosis

becomes more complete. Approximately one third of patients also have gastrointestinal upset

with nausea and vomiting. In some patients, scrotal trauma or other scrotal disease (including

torsion of appendix testis or epididymitis) may precede the occurrence of subsequent testicular

torsion.

A physical examination may reveal a swollen, tender, high-riding testis. The absence of

the cremasteric reflex in a patient with acute scrotal pain supports the diagnosis of torsion. In

time, a reactive hydrocele, scrotal wall erythema, and ecchymosis become more striking.
Differential diagnosis

 Torsion of testicular or epididymal appendage

o This condition usually occurs in children aged 7-12 years.

o Systemic symptoms are rare.

o Usually, localized tenderness occurs but only in the upper pole of the testis.

o Occasionally, the blue dot sign is present in light-skinned boys.

 Epididymitis, orchitis, epididymo-orchitis

o These conditions most commonly occur from the reflux of infected urine or from

sexually acquired disease caused by gonococci and Chlamydia.

o Patients occasionally develop these conditions following excessive straining or

lifting and the reflux of urine (chemical epididymitis).

o These conditions may be secondary to an underlying congenital, acquired,

structural, or urologic abnormality and are often accompanied by systemic signs

and symptoms associated with urinary tract infection.

o Pyuria, bacteriuria, or leucocytosis is possible.

o A complete urological evaluation (ie, renal sonography, urodynamic study) is

necessary in prepubertal boys with acute epididymitis.

 Hydrocele (usually associated with patent processus vaginalis)

o Painless swelling is usually present.

o Scrotal contents can be visualized with transillumination.

o Incarcerated hernia may be diagnosed by careful examination of the inguinal

canal.

 Testis tumor
 o Scrotal enlargement occurs, only rarely accompanied by pain.

o Presentation is rarely acute.

 Idiopathic scrotal edema

o Scrotal skin is thickened, edematous, and often inflamed.

The testis is not tender and is of normal size and position

Treatment

With prompt diagnosis and treatment the testicle can be saved in a high number of

cases.[2] In some cases the testicle can untwist on its own or it can be manually untwisted, which

can be attempted with pain relief as the guide for successful detorsion. Manual detorsion is

successful in 26.5% to greater than 80% of patients based upon a number of reviewed studies.[7]

Testicular torsion is a surgical emergency that needs immediate intervention.[2] If treated

within 6 hours, there is an excellent chance (90%) of saving the testicle. Within 12 hours the rate

decreases to 50%, within 24 hours is 10%, and after 24 hours the rate approaches 0.[2] Once the

testicle is dead it must be removed to prevent gangrenous infection.

 References
1. Karmazyn B, Steinberg R, Kornreich L et al (March 2005). "Clinical and sonographic

criteria of acute scrote in children: a retrospective study of 172 boys". Pediatr Radiol 35

(3): 302–10. doi:10.1007/s00247-004-1347-9. PMID 15503003.

2. Wampler SM, Llanes M (September 2010). "Common scrotal and testicular problems".

Prim. Care 37 (3): 613–26, x. doi:10.1016/j.pop.2010.04.009. PMID 20705202.

3. Ringdahl E, Teague L (November 2006). "Testicular torsion". Am Fam Physician 74

(10): 1739–43. PMID 17137004.

4. "Climatic Conditions and the Risk of Testicular Torsion in Adolescent Males".

Jurology.com. Retrieved 2011-09-28.

5. Lavallee ME, Cash J (April 2005). "Testicular torsion: evaluation and management".

Curr Sports Med Rep 4 (2): 102–4. PMID 15763047.

6. Arce J, Cortés M, Vargas J (2002). "Sonographic diagnosis of acute spermatic cord

torsion. Rotation of the cord: a key to the diagnosis". Pediatr Radiol 32 (7): 485–91.

doi:10.1007/s00247-002-0701-z. PMID 12107581.

7. "Testicular Torsion in Emergency Medicine". Emedicine.medscape.com. Retrieved 2011-

09-28.

8. Edelsberg JS, Surh YS (August 1988). "The acute scrotum". Emerg. Med. Clin. North

Am. 6 (3): 521–46. PMID 3292226.